Working with Your Pediatrician: Steven Parker, MD
By Steven Parker
The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician.
How do you choose a pediatrician? What do those well-baby checkups involve? Questions about newborns and immunizations? Developmental milestones? Trying to decide to circumcise or not circumcise? We discussed how you can work with your pediatrician as a team to provide your baby with the best possible start in life, and more, when WebMD's own in-house expert, Steven Parker, MD, was our guest.
Moderator: Welcome to WebMD Live. Our guest today is Steven Parker, MD, WebMD's own in-house pediatric expert.
Member: What questions should we ask when we interview pediatricians? Can you give us a list of criteria when choosing a pediatrician?
Parker: That's an excellent question. I always recommend, whenever possible, that parents interview a prospective new pediatrician. There are many questions that you want answered:
But more important than credentials is the sense of the pediatrician's competence, supportiveness, and friendliness that you get. Hopefully, you will have a long relationship with the pediatrician. Sometimes, when there are significant medical problems, that relationship can become very intense. It is very important that you feel comfortable with the pediatric clinician and that you feel confident in their expertise. You should feel like you should be able to talk with them about any topic -- be it medical, developmental, behavioral, or emotional issues.
Finally, ask your friends who they like and with whom they've had good success. Remember, however, that people have different tastes. Some like a pediatrician who tells you exactly what to do every step of the way. Others prefer a pediatrician who gives parents a range of options and then allows them to make a choice. Some prefer a pediatrician who has a very strict view of discipline while other parents are more comfortable with a more lenient view.
My advice: trust your gut. If you meet with someone and feel very positive with them, for whatever reason, go for it. If you have qualms and for some reason don't seem to connect, find another pediatrician.
p.s. I've used the term pediatrician. That's a bad habit because I am a pediatrician. Really, family practitioners, nurse practitioners, and other pediatric providers can do a terrific job with your child. So, I wouldn't let their professional training stand in the way of your working with them. Good luck in your quest!
Member: I live close to Massachusetts General Hospital in Boston. My question is should I go with the bigger hospital or private practice?
Parker: That's a very good question. There are advantages and disadvantages to both hospital-based pediatric practices and smaller, private practices. Often, hospital-based practices are staffed by pediatric residents in training. They can do a terrific job, but will only stick around for three years at most. On the other hand, a hospital usually contains every conceivable service and specialist that your child might need.
Private practices tend to be much more cozy. Although they can be quite busy, there are usually only a couple of pediatric providers who will be seeing your child. Usually, the pediatric staff has more experience than the residents and can more comfortably address the everyday issues. If you choose a private practice, ask which hospital they are affiliated with. Should problems arise, they would send your child to that hospital for further evaluation and treatment.
Either way, as I talked about in the previous question, the most important thing is to find a pediatric provider whom you really trust and like. When that happens, it doesn't matter much whether you're in a big hospital or a little office practice.
Member: Can you give some guidelines on when to call the doctor? Like for fevers, colds, diarrhea, or something that could be either serious or not? You don't want to be a pest or be too alarmed at every little thing.
Parker: Here are Dr. P's guidelines for calling the doctor:
1. Whenever you have significant concerns about your child, you should call (rightly or wrongly). Don't worry about being a pest. It's our job, not your job, to decide if your concerns are justified.
Fever alone (except in small infants) is usually not a good enough reason to call. Fever is a sign of infection, but this infection could be a mild virus or a bad bacteria. More important than the fever alone is how sick your child looks.
If the answer to any of these is yes, call. If, on the other hand, your child looks great but only has a fever, then it's OK to wait and see how things develop.
2. Dehydration concerns are another reason to call. If your child has vomiting or diarrhea or is not drinking well, you want to be sure that he is not dehydrated. Signs of dehydration include:
Call your pediatric provider whenever signs of dehydration occur.
3. It's also OK to call for nonmedical reasons. Your concerns may be more around a child's behavior and development than an acute medical issue. Don't be shy about trying to get some feedback from the pediatric practice about everyday developmental issues that come up (although calling in the middle of the night is not the best time)!
Those are Dr. P's rules. Bottom line: I'd rather you call your pediatric provider when you didn't need to than wait too long to call when you do need to.
Member: How far does the expertise of a pediatrician span? Is he or she limited to the sniffles and infections? At what point should you know to go to a specialist?
Parker: Pediatricians are trained to recognize almost any problem that might arise in a child. This includes even rare medical disorders. While we are trained to recognize them, we are also trained to know where our limits are and when to refer to a specialist. Sometimes this is a very clear decision and easy to make. Sometimes things are not going exactly as planned and it's not clear if a specialist's input might be helpful. There's no single answer to your question, I'm afraid. It underscores the importance of trusting your pediatric provider to know his or her limits and when a specialist should become involved.
If, however, you are dissatisfied with how things are going for some reason, it is perfectly legitimate for you to request a second opinion with a specialist, even if your pediatric provider does not agree.
Member: I've already been told my baby may have some special needs after birth. How can I find the best pediatrician for her?
Parker: As I said before, finding someone in whom you have great confidence and trust is the most important thing. In your case, you also want to ask [your doctor] to whom they send children with special needs. In general, you want to be sure they are using specialists and therapists who have experience in this area. You might also ask how many children with special needs are in their practice and ask to talk to a parent or two to see if they find the pediatric provider sensitive and receptive to their concerns. I wish you the best of luck.
Member: I am a first-time mom and expecting a boy. What do you think about circumcision?
Parker: This remains a very controversial area. Here's my opinion: Circumcision is a parental, not a medical, decision. There does appear to be a slight decrease in urinary tract infections in boys who are circumcised. However, it's not clear to me that this small difference in what is a rare event for boys, justifies routine circumcision. So I don't think the medical profession can tell you whether or not to circumcise your child. I think it's a parental decision. Parents have to decide how they feel about the question themselves. Is the father circumcised and do they want their child to look like the father? There may be religious reasons for circumcision in the family, which also must be considered. In other words, it's your call. Like most parents, I'm sure you'll make the right decision for your son.
Member: How late is too late to circumcise?
Parker: Well, I suppose it's never too late. Even adults have been circumcised for various reasons (ouch!). Generally, however, the younger the child is, the easier it is to do and the greater the chance they will have no memory of the procedure. That's why we like to do circumcisions in the first days, weeks, or occasionally months after delivery. Occasionally, however, it needs to be done after that and generally, succeeds just fine at that time also.
Member: Speaking of circumcision, I have a question about my 6-year-old son, who is not circumcised. Should his foreskin be retractable now? How do you tell if it is ready to pull back?
Parker: Good question! In the old days, for some reason, pediatricians were positively psychotic about retracting foreskins. I'm not sure what the reason was, but now we basically let nature take its course. There is no real reason to retract the foreskin at a young age. As the child grows and develops, nature will allow the foreskin to be retracted without any help from mom and dad. My advice is to leave it alone.
Member: How can you tell if your baby is allergic to something, like pets?
Parker: Allergies are very difficult to diagnose in infants and young children. None of the tests that we do on older children (like skin tests and some blood tests) are very accurate in infants. An infant with a constant runny nose might have multiple viral infections causing it. On the other hand, we might also suspect allergies in that infant, but it's difficult to prove until the same runny nose seems to recur at the same time every year or in response to close contact with Fido!
It's really detective work and my best advice if you're worried is to keep track of potential allergic symptoms (runny nose, watery eyes, sneezing) and what has happened in the hours before those symptoms occur. Then bring your notes to the pediatric provider and see if allergies could be in the picture and if so, an antihistamine, for example, could be considered.
Member: I have been breastfeeding my daughter since birth. When she was born, she was a full-term baby but weighed only 6 pounds. The doctor thought it was because I was under a lot of stress at that time in my life (I don't smoke or drink, so the low birth weight was not due to that). Once she was born, I breastfed her and she caught up with the average weight. But now, however, she has again slowed down significantly (she is 11 weeks). Her doctor blames it again on my high stress levels. I feel terrible about that, but I have to start her on formula. I would like to know what the chances are of her again joining the average curve?
Parker: That's a tough question to answer without more information. The question for me is why her weight gain has slowed down. Is it because she is not feeding as well as she used to? Is it because you're not making as much breast milk as she needs? Is she having vomiting or diarrhea? Is it a combination? So while I cannot make any guarantees, I will say that many babies have some temporary ups and downs in their weight gain. Most end up doing just fine. Since your little girl has shown us she can gain weight, I suspect she will again. I hope you continue to primarily breastfeed her, using formula only as a supplement when she seems to be hungry. Keep us posted on the WebMD parenting message board on how she's doing. Good Luck!
Member: Is it OK to give prune juice to an infant when he is constipated for days?
Parker: Yes. Personally, I like prune juice as an anticonstipation measure. Remember, however, how we define constipation. Constipation does not mean that the baby has not had a BM in a number of days. Constipation does mean that whenever the child goes, it is hard, and difficult to pass. In that case, I usually start with a little bit of half-strength prune juice to move things along. However, ask your pediatric provider his or her philosophy, also, before embarking on treating constipation in your baby.
Member: I am lactose intolerant, which developed later in life. Will my newborn have the same problem? How would I know if he is? I am planning on breastfeeding.
Parker: It's impossible to tell lactose intolerance ahead of time. Generally, we only suspect it when a baby has a long history of gastrointestinal disturbances. Even then, there can be many reasons for a stomach upset or diarrhea aside from lactose intolerance. Let's be optimistic and assume your baby will be able to digest milk sugar just fine. If he or she should begin to show signs of gastrointestinal disturbance, then we could put potential lactose intolerance on the list.
Member: I have a book that lists developmental milestones (when the baby will roll over, etc.). How concerned should I be if my baby doesn't match the milestone timetable in the book?
Parker: My advice: Throw the book away!! There is tremendous variability in normal babies of when developmental milestones are achieved. Some babies roll over within a few months and others take much longer. Some babies sit up sooner, some much later. Some babies walk at 9 months, some closer to 18 months. But if a baby is otherwise healthy and developing normally, it doesn't matter when these milestones are achieved. Every baby is different and I worry about parents who get anxious when their child does not exactly follow what the book says they should be doing. It's your pediatrician's job to watch for trouble in development. If he or she doesn't see any problems, don't worry about when a specific milestone is attained.
Member: We are taking our 4-month-old on a plane tomorrow. We are landing and taking off three times. I know I should feed him, but if he is not hungry can I give him water?
Parker: Sure. As you probably know, take off and landing are times when the pressure in the plane changes. This change in pressure can cause pressure to build up in the middle ear. This can be uncomfortable and make the baby a little miserable during those times. The key, then, is to have the baby swallowing frequently during takeoff and landing. This allows the pressure to equalize in the middle ear, so the baby does not experience that discomfort. Water would be fine. In a pinch, a pacifier or your finger can work if a baby refuses to take a bottle or breast altogether. In my experience, this usually is a good age to travel with a baby. Wait until he can walk, then life really gets tough on a plane.
Member: How soon after my baby is born do I need to see the pediatrician? What can I expect to happen during that first visit?
Parker: Most pediatricians schedule a visit about two weeks after the baby has gone home. That visit is mostly to see how things are going. The baby will be weighed and measured to make sure that milk intake and growth are acceptable. The pediatrician will do a careful physical examination to ensure the baby is healthy. But since most babies are healthy, sometimes the most important function will be to see how you, the mother, are doing. It's very difficult with a newborn baby. Many parents feel exhausted, stressed, and worried if they are doing a good job. A good pediatrician will spend as much time checking on your needs as a mother as he or she will spend checking into your baby's health. Fortunately, there are no immunizations to be given at the two-week visit.
Member: Does my 4-month-old daughter need water? I was under the impression that formula and solids provided the nutrition and "thirst" needs for a baby. Other moms and my mom say give it to them in small quantities. Which is appropriate?
Parker: This is one of those questions that people argue about all the time. That's probably because it just doesn't matter what you do. You certainly are correct that the fluid requirements for a baby are completely served by the milk (which, after all, is mostly water). There is no need to give babies supplemental water, unless it's extraordinarily hot outside and everybody needs extra fluids to keep themselves hydrated. On the other hand, it won't hurt a baby to give them water, either. So, whatever you do, the baby does great and everybody continues to argue that what they did with their baby is the right way to go.
Member: My son was exposed to chicken pox this morning at his playgroup. He has been vaccinated once against them ... will this ensure he is safe? Are there any precautions we should take, as his dad has never had chicken pox?
Parker: Since he has had the chicken pox immunization, it is unlikely he will get chicken pox. However, it still is possible that he could contract a mild case. This would show up in the next 10-21 days or so. If he were to get it, he would be contagious perhaps for a day or so before he actually got the rash. Obviously, if he does get the chicken pox rash, his father needs to avoid close contact until the rash begins to crust over. But, that's the worst-case scenario and the odds are good that he will never get chicken pox.
Moderator: We are out of time. Thanks to Steven Parker, MD, for being our guest, and thank you, members, for joining us today. Sorry we couldn't get to all of your great questions. For more pediatric information, please visit Dr. Parker's Parenting message board here at WebMD.
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